Provider Demographics
NPI:1114913365
Name:JEANSONNE, SUSAN WATTS (MD)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:WATTS
Last Name:JEANSONNE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 BROOKSIDE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4634
Mailing Address - Country:US
Mailing Address - Phone:423-224-3933
Mailing Address - Fax:423-224-3934
Practice Address - Street 1:2002 BROOKSIDE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4634
Practice Address - Country:US
Practice Address - Phone:423-224-3933
Practice Address - Fax:423-224-3934
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40530207P00000X, 208000000X
LAMD025360208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508394Medicaid
VA1114913365Medicaid
TN1508394Medicaid
TN103I377106Medicare PIN
TN3709285Medicare UPIN